0198 JEFFERSON AVE - BPA-08-332 What is the parent use of the Building?
�e9/dennr� /
Material of Building? E2V if dwelling.how many units?
Wil the Budding Conform to Law? T 4--& Asbestos? �n�--
ArcWdoas Naar
Address and Phone I
fdedwardes Name
Address and Phone
Construction Supervisors license* HIC Registration N
Gym Permit Fee Cala+latbn
Estimated�1�—
Permit Fee Estmated Cost X i7/51000 Residential
-- - - - Estimated Cost X$41f:1006Cornmercia�=-----An Additional $5.00 Is added as an
Administrative drargs.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury -
Date
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F •� F a G7C„ �
Erry-OF"8XLE�
PUBLIC PROPERTY
DEPARTMENT
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swukwsuaas.,,soi97o
11J.f74U&M 1 FAz 97a.7404W
APPLICATION FOR THE REPAIR RENOVATION_ CONSTRUCTION.
DILMOL —ON OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name 8 —�` i�f�.r ryyt_ tuilding
---- Properly A ------- —
Property is located Ina;Consaystlon Aros Y/N Hbtorlo Obbid Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: ✓ : o �®J� 2
Address j�T b /�C��i /ZSo^/ ft Sit Geys]
Tom:
3.0 COMPLETE THIS SECTION FOR WORK IN UILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
--- ------Mail Permit to: - - - -
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\t,u at 12C
To.97N4S•9S$S •F-M WS-74 -9aK
Construction Debris Dispossf Affidavit
(required for all demolition and renovation work) - -
In accordance with the sixth edition of the State Building Code, 7S0 Chift section 111.3
Debris,and the provisions of M. GL a 40.S X-
Building Permit a - . _ is issued with the condition that the debris resulting ftM
this wont shall be disposed of in a property licensed waste disposal facility as defined by.lGL c
l 11. S I SOA.
The debris will be transported by:
— — (norm of hauler)
the dcbds will be disposed of in
(name of txtf,ty)
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CITY OF S.U.EM
PUBLIC PROPERTY
DEPARTMENT
KI!W�4v rvtww�
120 wwvuNGW*Sn =6 U •M. &W01USUM 01970
7mi 978-74S-9S93* FNc:976-740.9a46
HOMEOWNER LICENSE EXEMPTION
Please Print
Date
Job Location /fl-- J-,c=�fr�tsm� ,¢vim_ 57v -r
Home Owner Address
Home Owner Telephone
Present Mailing Address jr.s~ c
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who,does not possess a license,provided that the owner acts as supervisor,
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on
which there is, or is intended to be,a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official,on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATL
APPROVAL OF BUILDING INSPECTOR ✓l
See other side for state code